On 4 February 2009, the Royal College of Physicians of London (RCP) published a report entitled Innovating for Health: Patients, Physicians, the Pharmaceutical Industry and the NHS.1 The report is the outcome of deliberations by a working party convened by the college in September 2007, chaired by Richard Horton (editor of the Lancet), and it comprises 70 pages and 42 recommendations. Despite its heritage the work is flawed, thereby diminishing the validity of the recommendations and the obligation to take them seriously.
The ideal working party has clear and understandable terms of reference; has a membership selected to tackle the problems at hand; concentrates primarily on resolving questions posed by its terms; produces a report that sets out the problems in such a way that each recommendation follows logically from the text; and finally, offers recommendations that are realistic and correctly targeted. In this instance, these ideals are often unmet.
Let us start with the terms of reference. Here the key request (presumably set by the RCP) is that the working party should "obtain evidence about the current and future prospects of the pharmaceutical industry" and about "the successes or failures in its relationships with the NHS and academic medicine." Then, armed with such information the working party should "identify policies that would promote . . . a relationship between the NHS, academic medicine and the pharmaceutical industry, the purpose of which is to discover and deliver safe, effective and affordable new medicines to patients based on need." Although time is spent on the delivery of safe and effective medicines, the group essentially ignores drug development, so almost no attention is paid to the direction of drug development. The report certainly has no regard for ideas of developing drugs to match patients’ needs and makes no recommendations relating to the affordability of drugs. These gaps, and the fact that the interests of patients seem to be a secondary consideration, give the report a hollow ring and its title an uneasy fit.
One possible explanation for the working party’s shift in direction is that its real agenda was to rehabilitate the image of the drug industry and its relations with clinicians and the NHS, which the group recognised were seriously hurt by the 2005 Health Select Committee’s report on the industry’s influence.2 As part of this rehabilitation, there is little direct criticism of the workings of industry or serious enquiry into how the industry might do better. So, in a short section on "Medical journals: victims or assailants," an opening salvo reads, "Editors of medical journals report examples of manipulation, distortion, bias, secrecy, overt promotion, and ghost writing in publishing medical research" and goes on to give detailed examples of the "excesses" of industry. The subsequent recommendation does not ask drug companies to refrain from such behaviour but instead turns its attention to the journals, asking editors "to do more to strengthen public and professional confidence." This stance defies logic.
If these problems were not enough, why do at least two recommendations (about the presentation of medicines) have essentially no supporting text? Why do some recommendations seem to be misdirected—why should doctors report a drug promotional violation to the Association of the British Pharmaceutical Industry’s code of practice authority, where it may be swept under the industry "carpet," when reporting to the Medicines and Healthcare Products Regulatory Agency could lead to prosecution in a criminal court? Why did the committee make a key recommendation on patients’ access to medicines that covers much the same ground as the Pharmaceutical Price Regulation Scheme published on 1 January 2009,3 as if it knew nothing about the new scheme although members of the committee who work for industry or the Association of the British Pharmaceutical Industry would have seen all the details in good time for the proposals to be incorporated? Why are many of the recommendations far from new—why do we need 42 when half that number would suffice—and why are the recommendations not numbered?
Notwithstanding these concerns, we would do well to adopt several of the recommendations. So—for example, more impartial information about medicines and treatments should be available to patients; we should have a national day to promote public awareness of medicines; the teaching of clinical pharmacology should be strengthened; students and doctors should receive no industry perks and the provision of postgraduate education should not depend on industry "generosity"; healthcare professionals with links to industry should make these public; ways should be found to strengthen research or working collaboration; and the Medicines and Healthcare Products Regulatory Agency should be more transparent.
Despite these positive recommendations the product of the working party’s deliberations is weakened by a flawed process, and so a real opportunity has been lost.
Cite this as: BMJ 2009;338:b443
Joe Collier, emeritus professor of medicines policy
1 St George’s, London SW17 0RE
1 Royal College of Physicians. Innovating for health: patients, physicians, the pharmaceutical industry and the NHS. Report of a working party. London: RCP, 2009.
2 House of Commons Health Committee. The influence of the pharmaceutical industry. Fourth Report of Session 2004-05. 2005. www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/42.pdf.
3 Collier J. Changes to the regulation of drug prices in the UK. BMJ 2008;337:a2735.[Free Full Text]
Relationships with the drug industry
What's the ideal relationship between the drug industry, academia, healthcare professionals, and patients? Five contrasting views discuss what it should be and the steps needed to be taken to achieve it. One argues there should be no relationship between the drug industry and either prescribers or patients. But others believe that there is a legitimate place for responsible collaboration.
Find out more:
More regulation, greater transparency
Keep at arm's length
Collaboration to improve care
Build trust based on good science
Focus on better information
Hat tip: MKM
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